We must defend personal continuity in primary care

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Helen Richards is to be commended for her ‘Personal View’ piece
emphasising the need to defend personal continuity in primary care in the
context of an evolving health care system. Current modernisation policies
and approaches to care do indeed continue to threaten this core attribute
of primary care. A key example of this is the introduction of new out- of-
hours arrangements for general practice services over the past decade
including walk-in centres, deputising arrangements and out- of- hours
general practice co-operatives. Despite this, there is a dearth of
empirical work exploring patients’ and care-givers’ perspectives of
continuity of care or rather ‘discontinuity’ in services such as these.

We have just completed a study on chronic patients’ perspectives on
continuity of care in an out- of- hours general practice co-operative in
the North West of Ireland which provides empirical evidence that these new
arrangements lead to what Richards refers to as the ‘compartmentalisation
of illness episodes’.

In this study patients with ongoing complex health care needs
described how they perceive chronic illness and the management of same as
a ‘journey’, what sociologists refer to as a ‘chronic illness trajectory’
(1). These patients assume that their personal general practitioners are
key co-ordinators of these health care journeys confirming Richards’ idea
that the definition of personal continuity may need to be extended to
incorporate the idea of the personal general practitioner being
responsible for co-ordinating the patient’s care in an increasingly
fragmented and complex health care system. From a sociological point of
view, the role of the personal general practitioner could be perceived as
that of ‘trajectory manager’ (1). As part of this role patients assume
and/or expect that their personal general practitioners should forward
information about their case histories to the out- of- hours co-operative
to ensure safe and appropriate management of their conditions in this
service. In practice however, this rarely happens. While this is not an
issue for many patients with less complex chronic conditions it has
significant consequences for the management of those with problematic
trajectories, that is, those described by Richards as having ‘multiple
morbidities’ and ‘convoluted health narratives’. For these patients
contact with the co-operative becomes a negative and distressing health
care experience. In light of these data we support Richards’ view that
policy needs to support continuity of care particularly, to think about
the heterogeneity of patients’ conditions and needs and the differential
impacts policies may have. This will increase the likelihood that those
who desire and are in most need of continuity of care get it when they
need it.

Helen Richards writes an eloquent plea for the defence of personal
continuity in primary care, despite the difficulties in defining and
quantifying it. I believe that continuity is valued by patients because of
the significance of the relationship between doctor and patient which can
then develop. Elsewhere in this issue, Anna Sobel and Farhana Mann write
of the importance of the feelings that patients elicit in us (and that we
elicit in them) as part of our relationship, and emphasise that this is an
integral part of every doctor-patient interaction.(BMJ 2009;339:b4063).
Barry Rapoport also describes the powerful physical effects of the loss of
an important relationship, and emphasises the indivisibility of mind and
body, in contrast to traditional medical Cartesian dualism.(BMJ
2009;339:b2383).

All these articles show how both we and our patients are affected by
our mutual interactions, whether we like it or not, and therefore how
important the relationship between doctor and patient is. Unfortunately,
as Richards describes, the current medical and political environment
values only those things that can be measured, and ignores and denies the
effects of the unquantifiable, such as relationships. As a result, we are
further pushed into treating patient's minds and bodies as separate
objects that have broken and need fixing, instead of finding ways to see
our patients as whole, complex human beings, profoundly affected by all
the relationships around them.

The nature of the relationship between doctor and patient underpins
everything we do, whether in general practice or psychiatry or even
surgery. The current pressures on all of us to measure and tick boxes push
us away from understanding and using that which our patients most value -
a trusting and responsive personal relationship.

It was a pleasure to read Helen Richard's Personal View and her
defense of personal continuity in Primary Care. it is a subject long
debated and it must be acknowledged 'personal lists' can mean more than
one form of arrangement. Nevertheless, it is a topic that has particular
meaning for current general practice with our political masters stressing
access and choice ahead of continuity of care.

There seems little doubt that personal continuity with one doctor is
valued by patients, particularly those with chronic disease. Little doubt
too that doctors themselves value continuity and find it professionally
satisfying. But is it better for general practice?

Those working in Primary Care know that there are huge organisational
problems mitigating against personal doctoring. Also, those practices that
think that they are offering continuity may not be, or at least be
offering, at best, a fragmented version. That is no reason though to ditch
the idea. The fact that continuity is harder to engineer and even harder
to measure does not mean it is of any less importance than speedy access.
Over thirty years in general practice taught me that most problems aren't
immediate, though to recognise the ones that are is of great importance.
Without continuity there is inevitably discontinuity. That too has its
down side -the more individuals involved in somerone's care the greater
the likelihood of errors, the less likely emotional problems are
adequately addressed and the more likely a relationship of trust (surely
the cornerstone of practice)fails to establish itself. Fourteen years
working with the Medical Defence Union, and longer still in the Courts,
has taught me the personal cost of discontinuous care.

The topic ought to be debated much more than it is in Journals like
this one and amongst those in position of influence such as the RCGP and
the BMA.Practices themselves need to make their views heard, now, before
government policy makers make personal continuity a thing of the past.